Gastric cancer: choice of operation and antibiotics - Forum

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Grandpa Phil

Gastric cancer: choice of operation and antibiotics - Ärzteforum

Post#1 »

A 72 old woman presented with UGI bleeding. For the last 6 month on Fe
supplement for anemia. Endoscopy shows a 10cm crater on the lesser curve,
and biopsies show adenoCA. The patient is a small woman, rather skinny,
but reports no recent weight loss. Patient is otherwise healthy. She is
active. Does her own shopping and housework, and passes the two bags one
flight test with ease. She has a supportive family.

On exploration there is a 10 cm mass on the lesser curve right up to the
GE junction. The mass seems to penetrate the tail of the pancreas.
and there are a few soft nodes on the lesser curve. There is no other
evidence of spread. Celiac nodes are not enlarged.

In order to rescet all gross tumor with adequate margins, one would need
to do a total gasterctomy, splenectomy and distal pancreatectomy. The
tail of the pancreas lifts easily off the celiac axis, and, technically,
resection is not too difficult, although jejuno-esophageal anastomosis
will have to be performed fairly close to diaphragm.

How many of my esteemed for-surgeons.com colleugues would embark on the more
radical resection, and who would choose instead a lesser procedure such as
total or near total proximal gastrectomy with shaving the pancreas,
leaving tumor behind. Or perhaps just a gastrojejunostomy. It is
impossible to exclude the tumor without closing the GE junction.

The second question I have, is that 36h after the operation the patient is
taken back for bleeding. The source is a small arterial branch near the
superior border of the pancreas. This is controlled, and the patient is
stable. Would anyone continue antibiotics beyond the perioperative period,
without evidence of infection?


User avatar
Surgeon

Re: Gastric cancer: choice of operation and antibiotics - Ärzteforum

Post#2 »

Firstly, anything you do with a T4 tumour is palliative. Secondly,
she is bleeding, so you have to do something.

> In order to rescet all gross tumor with adequate margins, one would need
> to do a total gasterctomy, splenectomy and distal pancreatectomy

A total gastrectomy is no big deal, and in a thin person the spleen
and distal pancreas deliver easily out the wound, although" shaving
off" might be better in the palliative situation.

> near total proximal gastrectomy
This is a mess: total or nothing.

Or perhaps just a gastrojejunostomy.

Wont stop the bleeding, and she isnt obstructed anyway.

User avatar
A Doctor

Re: Gastric cancer: choice of operation and antibiotics - Ärzteforum

Post#3 »

The total gastrectomy en bloc with pancreas and spleen is the way to go as it
provides the best palliation as well as only chance of cure If the tumor goes
up TO the GE junction you should be able to mobilize the esophagus
sufficiently not to be right at the hiatus--I also make it a habit to assure
your proximal margin is free by frozen section before anastomosing.
Stop the antibiotic-- unlike above, this is not a matter of opinion but well
established fact, that there is no benefit, and some harm, to prolonging
prophylactic antibiotic coverage.

User avatar
Old surgeon

Re: Gastric cancer: choice of operation and antibiotics - Ärzteforum

Post#4 »

Two questions on the same patient:

On exploration there is a 10 cm mass on the lesser curve right up to the
GE junction. The mass seems to penetrate the tail of the pancreas.
and there are a few soft nodes on the lesser curve. There is no other
evidence of spread. Celiac nodes are not enlarged.

In order to rescet all gross tumor with adequate margins, one would need
to do a total gasterctomy, splenectomy and distal pancreatectomy. The
tail of the pancreas lifts easily off the celiac axis, and, technically,
resection is not too difficult, although jejuno-esophageal anastomosis
will have to be performed fairly close to diaphragm.
ANSWER 1: So do it! This is a T4 situation, and you can handle it by
resecting the spleen and the tail of the pancreas too.
Any other operation is inadequate. Palliative operation could only be
justified, if there is no R0 situation possible, the patient apparently
too ill for it or the surgeon not experienced enough for extending the
operation.

The second question I have, is that 36h after the operation the patient
is taken back for bleeding. The source is a small arterial branch near
the superior border of the pancreas. This is controlled, and the patient
is stable. Would anyone continue antibiotics beyond the perioperative
period, without evidence of infection?
ANSWER 2: Why should one? Why to give antibiotics more than a single
shot in that patient? Pancreatic leakage, which may be a cause for the
bleeding, is never stopped by antibiotic treatment. If you have a hint
to that complication during your reoperation, try somatostatin or
octreotide (Nr. 1 better for not associated with narrowing of sphincter
oddi).

User avatar
Oncologist

Re: Gastric cancer: choice of operation and antibiotics - Ärzteforum

Post#5 »

the patient is bleeding, so you have to do something
or let she die with the tumour and a worst quality of life (soon will need
transfusions, pain, gastric obstruction and so on). The operation is a total
gastrectomy, and if it is easy, and in this case I mean very easy, remove
the pancreas and the spleen. Don't care about nodes, just remove the
peri-tumours.

I would continue antibiotics in this case, she had a reoperation, had an
important compication and is imunossupressed. In an ordinary case (no
complications), I use ATB for the first 24 hours only (usually a 2nd
generation cephalosporin and gentamycin).

What ATB did you use?
Was she in use or you have stopped and now reintroduced ATB?

John Dissector

Re: Gastric cancer: choice of operation and antibiotics - Ärzteforum

Post#6 »

Oncologist wrote:What ATB did you use?


This approach has long ago and firmly been refuted--it adds unnecessary
expense and risk to the patient for absolutely no gain, regardless of what
your opinion may be

User avatar
الجراح

Re: Gastric cancer: choice of operation and antibiotics - Ärzteforum

Post#7 »

Oncologist wrote:I would continue antibiotics in this case, she had a reoperation, had an
important compication and is imunossupressed. In an ordinary case (no
complications), I use ATB for the first 24 hours only (usually a 2nd
generation cephalosporin and gentamycin).

What ATB did you use?
Was she in use or you have stopped and now reintroduced ATB?


The patient is most probably not more immunosuppressed than any patient in
the same age going through major surgery. Although you may have to redose
your antibiotic DURING lengthy operations, you do not have to (and indeed
you should NOT) continue antibiotics for the mere fact that this is a
re-operation. I can see no reason here to deviate from the usual practice of
strict peri-operative antibiotic prophylaxis.

Surgical student

Re: Gastric cancer: choice of operation and antibiotics - Ärzteforum

Post#8 »

I would resect the mass en bloc as you described, trying to get a 5cm margin
proximally if possible. I have not had good luck with palliative procedures
for gastric carcinoma.
I would redose w/ antibiotics but stop after 24 hrs.
I always give these patients pneumovax and a bowel prep preop.

Marcel

Re: Gastric cancer: choice of operation and antibiotics - Ärzteforum

Post#9 »

The antibiotic issue is ofcourse a non-issue. The fate of the wound and
the operative site in terms of infection is determined DURING the operation
and not at it's aftermath. Any dose of postop antibiotics for whatever
duration won't change that fate!

About the operation in this case let me be a devil's advocate.
Ofcourse total gastrectomy with a distal pancreatectomy are a "fun"
procedure and a "piece of cake" for us big surgeons. But it is associated
with a well documented high M &M. Is the latter justified? Does it
translates to a better survival rate and better quality of life? This
lady was not really "bleeding", David- a little iron over 6 months is not
a "great deal" . You know that gastric ca patients very rarely
exanguinate. You mentioned "palliation" but what are you really palliating
here?

You are experts in ca stomach- are you convinced that
radical surgery will really prolong this patient's life and it's quality-
ofcourse if she survives with God's helps- and without antibiotics- the
"second hit".

Paranoid

Re: Gastric cancer: choice of operation and antibiotics - Ärzteforum

Post#10 »

Just to share with you all an operation from last year I regret. Patient with
prior total proctocolectomy for ulcerative colitis and a proximal gastric
lesion. In order to preserve maximum small bowel length we did a proximal
subtotal gastrectomy with esophageal gastric anastamosis and pyloroplasty.
Patient has reflux and developed stricture. He would have been better off
with total gastrectomy and roux-en-y reconstruction.

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